Dr. Peter Ubel is a physician and behavioral scientist at Duke, as well as an author and personal mentor/hero. I recently read his latest book, Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together, and recommend it highly to anyone interested in making the right medical decisions—either as a patient or a practitioner. I spent a lot of time with the topic when I wrote my Honors thesis, but Dr. Ubel‘s book beats everything else I’ve read at dissecting the psychological and historical quirks that make decision-making such a complicated issue. In addition, it offers a lot of concrete advice on how to do the decision-making dance better.
Dr. Ubel and I had this interview to elaborate on how his book applies to the Millennial generation and our unique medical needs. Because the conversation was so chock-full of decision-making goodness, we had to split it up into two parts—the second half can be found here.
KARAN: Though I hope our readers all read your book, for those who haven’t just yet, I want to start with an example that touches on the issues it discusses. I recently got a bad ankle sprain. The following week, I went to a local orthopedic surgeon for it. He was a very old-school doctor; before even talking about treatment options at all, he was getting his stuff out to give me a cortisone shot for my ankle. I was still trying to give him my history and symptoms and I had to stop to ask what he was doing. It was a little scary; I had no desire to get a shot, and from whatever little I know, I think cortisone might’ve even hurt more than it helped. But I’m obviously not residency-trained in orthopedic surgery, so I didn’t feel right questioning his opinion. So while I have seen how the patient autonomy movement has affected the way doctors are ethically trained, which you discuss in your book, I still think there are a lot of doctors who fit the old mold. As a patient, especially a young and inexperienced patient, it’s difficult sometimes to know how to respond.
DR. UBEL: I don’t think this is an old/young issue. If anything, people tend to think their older patients are more deferential than the younger ones. Most people in their 20s are more into the “consumer” mindset than older people who grew up in the “doctor knows best” era. But when you are young, the age difference between you and the doctor is bigger, so that could make it harder to be assertive when interacting with your doctor. But patients ought to feel they can assert themselves because, even for mundane issues, any time there’s more than one way to go about it, the patient deserves to know what their alternatives are and to be a partner in the decision. So what happened to you is not the best possible medical care. Whether the doctor made the right choice, that’s one thing. But if he didn’t say “One thing we could do is this, but you should know, there are other alternative. For example, if you don’t want to get a shot, we could just give it time, etc.” If the physician didn’t speak to you that way, that’s a problem.
I tend to think of these things in terms of power, and I felt like when I was in an office like that, and the doctor’s condescending to begin with, the power’s even more stilted than it would be if someone older had shown up there.
I bet it wouldn’t. I would guess that the physician you saw has fairly consistent ways of interacting with everyone. Maybe a little different in tone of voice, but he’s probably a physician that gives cortisone shots to many people with little explanation. He probably developed that style as a fast way to move people through the clinic. If doctors feel they have to give a long explanation about their therapies, and they are already behind on their schedules—it’s easy for them to say, “Here, take this shot,” without explaining the alternatives. Then they can more quickly move on to their next patient.
So, as a patient, what do you do? What do you recommend doing in a situation like that?
I think any time you’re with a doctor you want to say, “What are my alternatives?” And when the doctor says “There are none, this is the only way to go. I highly recommend it otherwise you’re gonna be in really big trouble”—if they’re uninformed, there’s just nothing as a patient you can do unless the stakes are so high you need a second opinion. But for a sprained ankle you’re not going to do that. So there are times you’re just going to see a doctor and be told there is only one treatment, and you have to trust that the doctor is correct. But you should always ask, “What are the alternatives?” Most doctors will take the time to explain the alternatives when reminded to do so.
That sounds like that wouldn’t be received poorly. Sometimes patients are concerned about seeming difficult—you remember that paper in Health Affairs, about how patients’ fear of seeming difficult impairs their participation.
Yes. The key is to ask the question in a way that won’t threaten your doctor.
But it sounds like that question shouldn’t really put off a doctor—it sounds like a good, nonthreatening question.
Doctors shouldn’t feel threatened by a simple query about “what are my alternatives.” But what do we do if doctors do act threatened? Should we go on some huge public service campaign to teach every patient to ask these questions, so doctors get used to that? It’s really hard to believe that approach would work.
But the more targeted thing to do is to train your next group of doctors not to act this way. The other thing you can do is—and this is probably unrealistic—to make communication training part of recertifications from physician boards. You could require physicians to audiotape conversations between them and their patients. We have lots of measures of physician quality, and if a doctor doesn’t measure up, they could be required to do a training module on them. If we found that a physician was having too many errors in the operating room—we don’t even do a great job of monitoring that—we’d address it. But since we measure quality of care, [sharing decision-making] is one of the things we ought to measure better, and there ought to be consequences if people don’t do it well. The consequences should start off with, “We want to help you do this better, we know you want to be a good doctor.”
Medicine is, historically, one of the most independent professions, so I can see why physicians wouldn’t want heavy-handed regulations on their practice. But when doctors are getting recertified, isn’t it common to have some sort of observed simulated exam?
It’s becoming more common, and there have been many debates over whether recertification works well at all. It definitely is expensive to start looking at, on the ground, what’s happening between doctors and their patients. But that’s certainly the direction that boards and certifying agencies should start moving in.
This is the first of a two-part series. For Part II, click here!
Karan is a first-year student at Robert Wood Johnson Medical School who previously worked in strategic research for hospital executives and graduated from Duke University.
Follow him on Twitter @KRChhabra.